In this section
purpose of the primary survey is to rapidly identify and manage impending or
actual life threats to the patient.
Always assume all major trauma patients have an
injured spine and maintain spinal immobilisation until spine is cleared.
Priorities are the assessment and management of:
Prior to arrival:
The life threat to identify and manage when
assessing the Airway is airway obstruction
This is typically the
responsibility of the "Airway Doctor" although it is a role which may
be shared with the "Assessment Doctor".
The Airway Doctor is typically
responsible for assessing the airway, the anterior neck and the GCS. Their goal is to ensure and maintain a patent
airway, through which the patient can be successfully oxygenated.
When assessing the airway. The airway doctor should start with assessing
Where the patient has suffered a burn, the airway doctor should look in particular for:
A complete airway assessment
also requires an assessment of the anterior neck - looking in particular for signs of blunt or penetrating trauma, or an impending airway life threat. This requires the airway doctor to open the
C-spine collar whilst an assistant maintains manual in-line stabilization of
the cervical spine. The Airway doctor should
then examine the anterior neck to look / feel for the following (TWELVE-C):
The airway doctor also needs
to assess the GCS
The life threat to identify when assessing the Airway is airway obstruction. Causes
of airway obstruction may be due to:
The management of airway obstruction is to ensure a patent airway through which
the patient can effectively be oxygenated.
This may require some or all of the following techniques:
The cervical spine should be protected by manual in-line stabilisation, followed by the rapid (gentle)
application of a properly fitted hard collar, sandbags and strap. (see
cervical spine assessment clinical practice guideline)
The life threats to identify and manage with regards to
The assessment of breathing, in the spontaneously ventilating child, is the responsibility of the assessment doctor. Where a child requires positive pressure ventilation (either bag-valve-mask ventilation, or intubated) there will be a shared responsibility for the assessment of breathing by the airway and the assessment doctors. At the start of the assessment, ensure all patients who are spontaneously breathing
have high flow oxygen applied – typically 10-15L O2 via a non-rebreather
mask. The child’s breathing is then assessed by observing:
Assessment of the thoracic cage requires feeling for:
The life threats to identify with regards to breathing include:
The management of these life threats
is typically carried out by the procedure doctor under direction from the Team
Leader. Once a life threat has been identified, the assessment doctor should communicate this to the Team Leader, and then continue on with the primary survey allowing the procedure doctor to carry out any interventions. Typical interventions include:
Intubated children may also benefit from the early insertion of a large
oro-gastric tube to treat and prevent gastric dilatation which in infants and
young children especially, can impair effective ventilation.
The major life threat to identify and manage with regards to circulation is
shock. However, obstructive shock does also occur, and causes for this should also be actively sought and managed.
The assessment of the circulation is
the responsibility of the “Assessment” Doctor. They should assess the child’s circulatory
It is useful for the assessment doctor to calling out
the patients vital signs at this stage of the assessment - so the team is aware of them. The assessment doctor should continue with a focused assessment that involves looking for sites of potential bleeding. These include the following sites:
The assessment doctor should, in consultation with the Trauma Team Leader, consider the need for a pelvic x-ray (see also Pelvic Injury CPG).
The major life threat to identify
with regards to circulation is haemorrhagic shock
care should be taken to actively look and exclude:
The management of haemorrhagic
shock is to identify and stop the source(s) of bleeding whilst concurrently resuscitating
the patient. The management of these life threats may need multiple team members and is co-ordinated by the Trauma Team Leader. Once the assessment doctor has identified these life threats, they must communicate their findings to the Trauma Team Leader, then continue with the primary survey. The management of haemorrhagic shock may include:
Assess the child's circulatory state by observing:
The life threat to identify is traumatic brain injury
The assessment of 'Disability' is typically the responsibility of the airway doctor - although the assessment doctor may add and complement to this by assessing peripheral function. Initial assessment
of the level of consciousness may be done using the AVPU assessment:
impairment on detected on the AVPU scale should prompt a formal assessment of
the patient’s GCS (link to GCS-level of consciousness in Head Injury CPG). Pupil
response to light should be noted, as should movement in all four limbs. The assessment doctor should check for this as well as reflexes if the prior to intubation where possible. The
blood glucose level should be measured on arrival and periodically during the
management of the trauma patient.
life threat to identify is traumatic brain injury
- whilst the primary brain injury cannot be reversed, secondary brain injury
can be minimised by the prevention of hypoxia/hypotension and instigation of neuroprotective
strategies to minimise intracranial pressure, along with the expedited progress
of the patient to CT imaging of the brain, and then to a site capable of any
necessary neurosurgical intervention.
Remove clothing initially and
look for any other obvious life threatening injury. Avoid
hypothermia by limiting exposure of the body, and by warming all ongoing
secondary survey is commenced after the primary survey has been completed,
immediate life threats identified and managed, and the child is stable.
Continue to monitor the child’s:
Any unexpected deterioration
in these parameters require reassessment and management of evolving life
Before commencing the
Inspect the face and scalp. Look
specifically at the:
Test eye movements, pupillary
reflexes, vision and hearing
the neck - it is necessary to open the collar to do this - whilst maintaining manual
in-line stabilisation of the neck. Examine the anterior neck (as per the
primary survey) checking for:
Asses the c-spine by palpation of the cervical vertebrae (see Cervical spine assessment CPG)
the chest, observe the chest movements. Look
in particular for:
for clavicular and rib tenderness and auscultate the lung fields and heart
Inspect the abdomen, the perineum and external genitalia. Look for in particular for:
Palpate for areas of tenderness especially over the liver, spleen, kidneys and bladder, and auscultate bowel sounds.
Inspect the pelvis for grazes
over the iliac crest. Examine for bruising, deformity,
pain or crepitus on movement.
all the limbs and joints, palpate for bony and soft tissue tenderness and check
joint movements, stability and muscular power. Examine
sensory and motor function of any nerve roots or peripheral nerves that may
have been injured.
A log roll should be performed either in the primary survey or in the secondary survey.
Interpretation of the
urine dipstick in blunt paediatric trauma suffers from high rates of false
positive and false negative results – formal microscopy is the better test
where renal injury is suspected.
During the examination,
any injuries detected should be accurately documented, and any urgent treatment
required should occur, such as covering wounds and splinting fractures. Appropriate analgesia,
antibiotics or tetanus immunisation should be ordered.
Following the secondary
survey, the priorities for further investigation and treatment may now be
considered and a plan for definitive care established. At this stage the patient may require
advanced imaging in CT, or transfer to the ward, intensive care or theatre.
Typically the trauma team
leader will remain responsible for the patient until they have completed their
imaging and arrived at their inpatient destination. Handover of care may occur sooner than this –
for example if the anaesthetist is present in the ED and will accompany the
patient to theatre or intensive care. On
these occasions formal handover where the new team leader and team acknowledge
that responsibility for the patient has
been transferred. A departure checklist
made aid in this process.